This article situates the new coronavirus disease (COVID-19) pandemic in a scenario of securitization of global health. I address the pandemic as a crisis of the neoliberal economic model and the result of a process of growing vulnerability due to neoliberalism. The pandemic calls on us to rethink the vulnerabilities resulting from global interconnectedness. I highlight the importance of public and participatory health in the context of a reflection on the possibilities for sustainable life with solidarity on a global scale.

Securitization and the crisis of neoliberalism

In recent years, securitization has become one of the most important lenses for interpreting global health 11. Ventura DFL. Do Ebola ao Zika: as emergências internacionais e a securitização da saúde global. Cad Saúde Pública 2016; 32:e00033316.. Describing a specific modality of the nexus between health and security, this theory contends that the statute of “threat” results from an interaction between an actor that attempts to define a given issue as an existential threat and an audience that accepts or rejects this attempt. What distinguishes a process of securitization is the defense of extraordinary measures - including the suspension of (or exceptions to) normal processes of democratic deliberation - as necessary responses to this existential threat 22. Buzan B, Wæver O, De Wilde J. Security: a new framework for analysis. Boulder: Lynne Rienner Publishers; 1998.. This analytical approach has been used to analyze cases such as SARS, avian flu, Ebola, and Zika, among others 33. Curley MG, Herington J. The securitisation of avian influenza: international discourses and domestic politics in Asia. Rev Int Stud 2011; 37:141-66.,44. Enemark C. Ebola, disease-control, and the Security Council: from securitization to securing circulation. Journal of Global Security Studies 2017; 2:137-49.,55. Wenham C, Farias DB. Securitizing Zika: the case of Brazil. Secur Dialogue 2019; 50:398-415..

COVID-19 confirms the dynamic of securitization of global health. The pandemic has been framed in the context of a threat to people’s lives and to the regular functioning of societies. It was not just about the securitization of the disease, which for the majority of infected individuals is either asymptomatic or shows moderate symptoms. However, COVID-19 has a higher case-fatality rate than influenza A; the incubation period is 1 to 14 days; and it includes community transmission (possibly even during the asymptomatic period) via droplets from coughs and sneezes, and also via contact with contaminated surfaces or objects 66. Anderson RM, Heesterbeek H, Klinkenberg D, Hollingsworth TD. How will country-based mitigation measures influence the course of the COVID-19 epidemic? Lancet 2020; 395:931-4.,77. World Health Organization. Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations. https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations (acessado em 27/Mar/2020).https://www.who.int/news-room/commentari... . Given these specificities, there has in fact been a securitization of the circulation of persons and social contact - that is, securitization of factors that can lead to exponential growth in the number of serious cases and consequently a collapse in healthcare services. In many countries, the response has resulted in a scenario of exception, with confinement and social distancing policies. Emergency declarations have given additional powers to authorities and have led to militarization of the response in some countries. Aside from a few cases, societies have accepted this state of exception.

Securitization of circulation and contact is a new fact that this crisis has brought to global health. Historically, the objective of global health governance has been to prevent national disease control measures from excessively affecting the circulation of persons and goods 88. King NB. Security, disease, commerce: ideologies of postcolonial global health. Soc Stud Sci 2002; 32:763-89.. The 2005 International Health Regulations, for example, specify under which circumstances national governments can impose additional control measures to those proposed internationally. Health security mechanisms emerged as part of a liberal worldview that aims to install and maintain a “triage” between economically necessary circulation (that should be promoted) and circulation that is harmful to the economy 99. Foucault M. Security, territory, population: lectures at the Collège de France, 1977-78. Houndmills: Palgrave MacMillan; 2007.. With COVID-19, and although the restrictions on circulation do not include goods and information, global health governance has sacrificed a significant component in the triage, placing severe limits on economically necessary circulation. The result has been a set of economic consequences that may exceed the effects of the 2008 financial crisis.

Securitization is normally a mechanism for protection of the economy, but in the case of COVID-19 it has been used for purposes contrary to the economy. It is no coincidence that in countries like Brazil the resistance to securitization has been based on the argument that “the economy cannot stop”. This argument is correct - if one takes it as a manifestation of what has been called “epidemiological neoliberalism” 1010. Frey I. "Herd immunity" is epidemiological neoliberalism. https://thequarantimes.wordpress.com/2020/03/19/herd-immunity-is-epidemiological-neoliberalism/ (acessado em 27/Mar/2020).https://thequarantimes.wordpress.com/202... . Since the economy is organized in a neoliberal format, it cannot withstand a suspension of circulation, even temporary. COVID-19 thus reveals neoliberalism’s lack of resilience when exposed to a global and large-scale shock originating from a non-economic or non-financial sector. The pandemic further demonstrates neoliberalism’s contradictions, demanding circulation even when such circulation provenly promotes the sickness and death of a significant contingent of the population. Thus, COVID-19 is not only a public health crisis, but also a crisis of the neoliberal model. Capitalism has been noteworthy in its own reinvention over the centuries, assimilating criticisms in various situations in order to strengthen itself 1111. Boltanski L, Chiapello E. Le nouvel esprit du capitalisme. Paris: Gallimard; 1999.. A new reinvention is possible. It is also possible that the illusion will be maintained, i.e., that neoliberal business-as-usual can be restored. But we do not have much time. In a situation of climate emergency, with the increasingly obvious unsustainability of an economic model based on uninterrupted growth, conspicuous consumption, waste, and the destruction of biodiversity, the consequences of COVID-19 may actually be foretelling the future.

Global vulnerability

The COVID-19 pandemic means not only a crisis of neoliberalism as an economic model; the pandemic itself is a neoliberal crisis. The historical trajectory of global health can be interpreted from the perspective of the expansion of neoliberalism, especially since the 1980s 1212. Keshavjee S. Blind spot: how neoliberalism infiltrated global health. Berkeley: University of California Press; 2014.. Neoliberalism, based “on the primacy of the market, competition, minimal state intervention, and private sector efficiency” 1313. Harman S. Global health governance. Abingdon: Routledge; 2011. (p. 5), took shape in structural adjustment policies focused on containing public spending, which in turn resulted in the underbudgeting and dismantlement of public health systems throughout the world. This tendency was aggravated by the 2008 financial crisis, to which many governments responded with austerity policies that lent new impetus to the neoliberal project of delegitimizing health as a public good. The consequences are well-documented by the deterioration of key health indicators 1414. Schrecker T, Bambra C. How politics makes us sick: neoliberal epidemics. Houndmills: Palgrave MacMillan; 2015.,1515. Labonté R, Stuckler D. The rise of neoliberalism: how bad economics imperils health and what to do about it. J Epidemiol Community Health 2016; 70:312-8..

Beyond these adverse effects, neoliberalism has resulted in greater global vulnerability to epidemic shocks like COVID-19. In this context, the pandemic is a political phenomenon with its roots in our recent neoliberal past. The history of COVID-19 is made of actions and omissions in recent decades that have reduced health systems’ capacity for surveillance, containment, and mitigation of epidemics. This history is made of political choices that have exacerbated economic inequality, made work more precarious, and undermined public services, which in turn have left a significant portion of the population in a situation of vulnerability to the disease and of incapacity to deal with its consequences. Meanwhile, the pandemic’s history is made of socioeconomic and cultural dynamics in the organization of work and social relations 1616. Sennett R. The corrosion of character: the personal consequences of work in the new capitalism. New York: WW Norton & Company; 1998.,1717. Scharff C. The psychic life of neoliberalism: mapping the contours of entrepreneurial subjectivity. Theory Cult Soc 2016; 33:107-22.. Culturally, neoliberalism is reflected in social atomization, the promotion of individualism and competitiveness, and the destruction of networks of solidarity and empathy that are essential for the joint effort that the response to COVID-19 requires.

Vulnerability is one of the most relevant problems in this pandemic, showing how each person’s health depends on the actions and omissions of others, and how the pursuit of total invulnerability is an illusion. To a certain extent, vulnerability is inevitable, resulting from our fragile bodily condition and the social nature of human life 1818. Butler J. Undoing gender. Abingdon: Routledge; 2004.. Our growing global interconnectedness and interdependence, reinforced by the globalization of capitalism, has added to this vulnerability by drawing societies closer together and increasing the human capacity to inflict harms beyond borders 1919. Linklater A. The problem of harm in world politics: theoretical investigations. Cambridge: Cambridge University Press; 2011.. COVID-19 has demonstrated the sharply growing vulnerability of daily life under neoliberal capitalism. To our inevitable vulnerability, neoliberalism has added successive layers of “pathogenic” vulnerability based on “morally dysfunctional or abusive interpersonal and social relations and oppression or sociopolitical injustice” 2020. Mackenzie C, Rogers W, Dodds S. Introduction: what is vulnerability and why does it matter for moral theory? In: Mackenzie C, Rogers W, Dodds S, editors. Vulnerability: new essays in ethics and feminist philosophy. Oxford: Oxford University Press; 2014. p. 1-29. (p. 9). Inequality, precariousness, and privatization of health, among other phenomena, reveal the neoliberal dynamics of exploitation underlying our vulnerability to pandemics such as COVID-19.

Another relevant aspect of vulnerability is the fact that it is not uniform. COVID-19, as a global social fact (facilitated by the circulation of information via social networks), can lead us to believe in an equality of conditions. One of global health’s most popular narratives is precisely the notion that we are “united by the contagion” 2121. Zacher M, Keefe TJ. The politics of global health governance: united by contagion. Houndmills: Palgrave MacMillan; 2008.. But let us not fool ourselves. This is not one single pandemic, but various experiences of the pandemic. We are not “all in this together”. As a white man, comfortably staying at home while receiving my salary, I cannot compare my experience to that of a person with precarious work or prevented from working and earning, or even living on the street. Vulnerability is an unequal political relationship by which certain groups - defined in terms of gender identification, race, sexual orientation, and age, among others, as well as in their various intersections 2222. Crenshaw K. Mapping the margins: intersectionality, identity politics, and violence against women of color. Stanford Law Rev 1990; 43:1241-99. - are systematically exposed to impoverishment, illness, and death.

The first lesson from COVID-19 is the need for a political reopening. Part of the force of neoliberalism stems from its façade of inevitability, since it draws on the idea that there is no alternative to the austerity that aims to deflate the State as a guarantor of the common good. The COVID-19 pandemic shows that true resilience lies neither in the market (which is usually the first thing to collapse when a large-scale shock occurs) nor in privatized health. Resilience comes from strengthening a public and universal system, based on the premise of health as a common good and on social participation as an essential democratic mechanism for the health system’s definition and implementation.

The second lesson is the need for an awareness of limits and finitude. The trajectory of COVID-19 and its short- and long-term consequences hinge not only on an abstract neoliberalism, but on individual behaviors: the decision to stay at home or leave; the information we produce and share; what, when, and how much we consume; the choice between solidarity, the pursuit of self-interest, or the stigmatization of others; in short, our proximity or distance, both in physical and ethical terms. As in the case of the climate emergency, but with greater visibility, the COVID-19 crisis raises a challenge for us that plays out largely in individual choices, but which extends far beyond such choices. It is about reconciling the realignment of individual choices with the definition of a collective response on the global scale. Central to the response to this challenge will be to rethink the premises of a common and sustainable life with solidarity and the awareness of our shared vulnerability, and the way this vulnerability is reflected in multiple and unequal experiences.